Provider Demographics
NPI:1780657106
Name:VANCLEVE, MICHAEL (MA LP LADC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:VANCLEVE
Suffix:
Gender:M
Credentials:MA LP LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1374 SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2411
Mailing Address - Country:US
Mailing Address - Phone:651-647-5602
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 435S
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-647-1900
Practice Address - Fax:651-647-1861
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3135103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist